Atrial Flutter Without Haemodynamic Instability — When Initial Acute Therapy Has Not Achieved Rate or Rhythm Control
This protocol addresses haemodynamically stable patients with atrial flutter in whom the initial acute management strategy — rate-control agents or cardioversion — has not achieved conversion to sinus rhythm, termination of the flutter, or adequate control of the ventricular rate.
Clinical scenario
The patient remains haemodynamically stable without signs of circulatory compromise, allowing a stepwise approach to be followed. The absence of haemodynamic instability defines the treatment context and the selection of next-line options.
Previous therapy — failure condition
First-line acute therapy — including intravenous agents for rate control and/or cardioversion strategies (electrical or pharmacological) — did not achieve the target goals: conversion to sinus rhythm, termination of atrial flutter, or control of the rapid ventricular rate. This protocol outlines the structured step taken after that failure.
Next-step approach
When earlier measures are not available or suitable, the approach may involve an intravenous antiarrhythmic agent; additionally, pacing-based strategies — including non-invasive approaches — are an option for terminating the flutter.
Clinical goals: conversion to sinus rhythm / termination of atrial flutter; control of ventricular rate.
The complete decision path — agent selection, sequencing, and full clinical algorithm — is available in the structured protocol.
References
DOI: 10.1093/eurheartj/ehz467
Haemodynamically stable patients
i.v. amiodarone may be tried if the above are not available or desirable.
Invasive and non-invasive high-rate atrial pacing may be considered for termination of atrial flutter.
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